Clinical Review Coordinator

About the role

The Clinical Review Coordinator conducts all mandatory case review and quality assurance activities as stipulated by contracts and maintains the required timeliness and accuracy within the review process. The role is remote work, but you must reside in the Las Vegas, NV area.

Responsibilities

• Maintains responsibility for assuring an efficient case review process through the production system.
• Identifies and corrects problem areas on a case-by-case and system-wide basis.
• Interprets and applies coverage and payment policies, standards of care, and utilization review criteria applicable to a specific position.
• Communicates with and supports physician reviewers by summarizing case facts, preparing case questions, and resolving physician input issues.
• Informs Medicare beneficiaries, health care providers, and other partners of the activities and responsibilities of the Quality Improvement Organization (QIO).
• Edits documentation for internal and external dissemination to beneficiaries, providers, and other medical personnel.
• Protects the confidentiality of patient information through compliance with the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH).
• Performs desktop medical reviews.
• Attends annual security awareness, rules of conduct, and conflict of interest training.
• Performs other duties as assigned.

Essential Knowledge

Individuals must be detailed oriented and clinically knowledgeable of medical terminology.

Essential Education

• Graduation from an accredited school of nursing and current unrestricted licensure as a Registered Nurse (RN) or Licensed Practical Nurse (LPN).
• A degree in a healthcare-related field with a professional clinical background and experience with Medicare QIO.
• Quality of care review experience or medical review experience in support of Medicare Administrative Contractor (MAC) or Recovery Audit Contractor (RAC) appeals. Experience performing pre- and post-pay claims reviews, and utilization reviews may also qualify.
• Minimum of two to four years of experience in clinical decision-making relative to Medicare patients.

Essential Skills

• Ability to organize and coordinate multiple simultaneous tasks in a team environment.
• Ability to follow complex written and oral instructions.
• Ability to collect data, distinguish relevant material, and exercise sound judgment.
• Ability to apply problem-solving skills and maintain objectivity.
• Strong computer keyboarding skills.
• Ability to work independently with minimal supervision.
• Ability to communicate accurately, consistently, timely, clearly, empathetically, respectfully, and effectively with beneficiaries, representatives, and providers, both verbally and in writing.

Organizational "Fit" Considerations

Schedules may vary and may include weekend and holiday shifts. This position requires established, professional relationships with internal personnel at all levels within the company and with beneficiaries, representatives, providers, and other stakeholders.

Work Environment/Physical Demands

This is an office/remote position. While performing the duties of this job, the employee regularly works in a climate-controlled environment. Candidates must be able to sit, read, work on a computer, and watch a computer screen for extended periods of time. Occasionally required to stand, walk, use hands and fingers, kneel or crouch.

Equal Employment Opportunity

Commence is an equal employment opportunity employer. All personnel processes are merit-based and applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military and veteran status or any other characteristic protected by applicable law.